Internal and external focus of attention during gait re-education: an observational study of physical therapist practice in stroke rehabilitation

A pilot cluster randomised controlled trial, of an IMPlicit learning approach versus standard care, on recovery of mobility following stroke (IMPS)

OBJECTIVES

To evaluate the delivery of rehabilitation using implicit motor learning principles in an acute stroke setting.

DESIGN

Pilot, assessor-blind, cluster randomised controlled trial with nested qualitative evaluation.

SETTING

Eight inpatient stroke units, UK.

PARTICIPANTS

People within 14 days of stroke onset, presenting with lower limb hemiplegia.

INTERVENTIONS

Participants at control clusters received usual care. Participants at intervention clusters received rehabilitation using an Implicit Learning Approach (ILA); primarily consisting of reduced frequency instructions/feedback, and promotion of an external focus of attention. Video recording was used to understand the ability of intervention site therapists to adhere to the implicit learning principles, and to compare differences between groups.

MEASURES

Ability to recruit and retain clusters/participants; suitability and acceptability of data collection processes; appropriateness of fidelity monitoring methods; and appropriateness of chosen outcome measures.

RESULTS

Eight stroke units participated, with four assigned to each group (intervention/control). Fifty-one participants were enrolled (intervention group 21; control group 30). Mean time since stroke was 6 days (SD 3.42; 0-14); mean age was 73 years (SD 14, 25-94). Of those approached to take part, 72% agreed. We found clear differences between groups with respect to the frequency and type of instructional statement. The ILA was acceptable to both patients and therapists.

CONCLUSION

It is feasible to evaluate the application and effectiveness of motor learning principles within acute stroke rehabilitation, using a cluster randomised design. A larger study is required to evaluate the benefits of each approach; we provide a range of sample size estimates required for this.

Serial engagement of distinct motor learning mechanisms to alter walking after stroke

This study asked if combining different motor learning mechanisms-adaptation and reinforcement-could produce immediate improvements in over ground walking after stroke. Fifteen adults with stroke engaged in three conditions: (1) reinforcement following adaptation, (2) reinforcement alone, and (3) adaptation alone. Adaptation involved split-belt treadmill walking to produce after-effects that reduce step asymmetry. Reinforcement involved the use of real-time auditory feedback about step length asymmetry. Auditory feedback was binary, signaling whether steps were asymmetric or equal, but not whether to shorten or lengthen either step. Change in step length asymmetry was the outcome assessed during over ground walking. Reinforcement following adaptation led to reductions in step length asymmetry that persisted into an immediate retention period. Importantly, it led to the desired pattern of lengthening the shorter step in a majority of participants. Reinforcement alone led to no significant change in step length asymmetry, and sometimes produced a non-optimal pattern of shortening the longer step. Our control condition of adaptation alone led to more transient reductions in step length asymmetry. These findings reveal the potential for utilizing serial delivery of adaptation and reinforcement to influence a complex movement in the real-world context of over ground walking, in people with stroke.

The effectiveness of different attentional foci on the acquisition of sport-specific motor skills in healthy adults: a systematic review with network meta-analysis

Background

The acquisition of motor skills is a key element in many sports. A motor learning principle, which is frequently used to support skill acquisition is the application of different attentional foci. The effectiveness of different attentional foci on performance and the learning of motor skills has been investigated in various sports using randomised controlled trials. The aim of the present study was to investigate the effectiveness of different attentional foci (such as external (EFA) and internal attentional foci (IFA), but also holistic and switching foci) on the performance and learning of a sport-specific motor task in healthy individuals.

Methods

This study was a systematic review with network meta-analysis. We followed the Prisma reporting guideline and the Cochrane handbook for systematic reviews. Cinahl, Embase, Medline and Cochrane Central were searched for eligible studies. Network meta-analyses were performed for the post-acquisition, retention and transfer test endpoints.

Results

Twelve studies were included in the review. At post-acquisition an EFA was the most effective intervention compared to the control intervention (SMD: 0.9855; 95% CI [0.4-1.57]; p: 0.001). At the retention and transfer test endpoints, a holistic focus of attention had the highest effectiveness compared to an IFA (SMD 0.75; 95% CI [-0.1 to 1.6]; p: 0.09) and (SMD 1.16; 95% CI [0.47-1.86]; p: 0.001).

Discussion

For all three endpoints, we analysed a greater effectiveness of an EFA and holistic focus compared to an IFA. Several promising different attentional focus interventions were identified. The largest effects were analysed for a holistic focus. However, only one study used this intervention and therefore there remains uncertainty about the effectiveness. With regard to the inconsistency observed, the analysis at post-acquisition should be interpreted with caution. Modified versions of the EFA were the imagined and the dynamic EFA. Both were only explored in single studies and should therefore be investigated in further follow-up studies that directly compare them.

Explicit Instruction May Impair the Transfer of Motor Adaptation in an Upper Extremity Motor Task

This study focused on explicit instruction and evaluated the differences in task performance between participants who were instructed to employ the change and those who were not. Ninety-three healthy young adults were assigned to the accurate information group (AG; n = 31), misinformation group (MG; n = 31), and non-information group (NG; n = 31). All participants manipulated a mouse to track a moving target on a screen with a cursor. The cursor was rotated to 60° in the clockwise direction from the actual mouse position during the 1st to 5th blocks (i.e., motor adaptation task). Subsequently, in the 6th block (i.e., transfer task), we gradually changed the angle of rotation from 60° to 80° to prevent from noticing the change. Participants in the AG were instructed accurate experimental information. Participants in the MG were instructed that the angle of rotation was 60° during the 1st to 6th blocks. Participants in the NG were instructed to manipulate the cursor movement only. The results indicated that an average error distance in the AG was significantly lower than that in the NG in the 6th block. This study suggested that explicit instruction may impair the transfer of motor adaptation in this setting.

Do the effects last? A comparison between internal and external focus of attention instructions on golf putting accuracy over multiple days

Background

The role of attentional focus is a well-explored topic in exercise sciences. Studies generally indicate that external focus (EF) enhances motor performance and learning compared with internal focus (IF). However, most studies only included one or two experimental days which limits participants' exposure to the focus conditions. This raises the question of whether the superiority of EF varies over time.

Methods

Accordingly, in this pre-registered within-subject study, we examined the effects of focus instructions on golf-putting performance over four days, with 48-72 h between them. On each day, participants performed 15 putts under three instructional conditions: (1) EF, (2) IF, and (3) control, in a randomized and counterbalanced order.

Results

We observed trivial differences in performance between conditions but considerable improvements from day 1 to day 4. When using an exploratory analysis, we found that participants performed better under EF and control conditions compared with the IF condition on day 1, but not on subsequent days.

Conclusions

Since IF instructions are more commonly used in practice, we speculate that the two other focus conditions were experienced as more novel, potentially accounting for their superiority on Day 1. Nevertheless, our results question the significance of employing EF to enhance performance.

Influence of Verbal Instruction on Gait Training in Parkinson Disease: A Randomized Controlled Trial

OBJECTIVE

Verbal instruction is one of the most commonly used methods that therapists use to correct walking pattern for people with Parkinson disease. This study aimed to compare the long-term training effects of two different verbal instructions that either asked the participants to "take big steps" or "strike the ground with the heel" on walking ability in individuals with Parkinson disease.

DESIGN

Forty-five participants with Parkinson disease were randomized into the big-step or heel strike group. The participants underwent 12 sessions of treadmill and overground gait training. Throughout the interventions, the big-step group received an instruction to "take big steps," while the heel strike group received an instruction to "strike the ground with your heel." The primary outcome was gait performance, including velocity, stride length, cadence, and heel strike angle. The participants were assessed before, immediately after, and 1 mo after training.

RESULTS

Both groups showed significant improvements in gait performance after training. The heel strike group showed continuous improvements in velocity and stride length during the follow-up period; however, the big-step group showed slightly decreased performance.

CONCLUSIONS

A verbal instruction emphasizing heel strike can facilitate long-term retention of walking performance in people with Parkinson disease.

Does having an external focus in immersive virtual reality increase range of motion in people with neck pain?

BACKGROUND

When instructing exercises to improve Range of Motion (ROM), clinicians often create an internal focus of attention, while motor performance may improve more when using an external focus.

OBJECTIVES

Using Virtual Reality (VR), we investigated the effect of tasks with an internal and external focus on maximal ROM in people with neck pain and explored whether this effect was associated with fear of movement.

METHOD

In this cross-over experimental design study, the cervical ROM of 54 participants was measured while performing a target-seeking exercise in a VR-environment (external focus task) and during three maximal rotation and flexion-extension movements with the VR-headset on, without signal (internal focus task). The main statistical analysis included two dependent T-tests. Pearson correlation coefficients were calculated to investigate whether the differences in ROM in both conditions were correlated to fear of movement.

RESULTS

Maximal neck rotation was larger in the external focus condition than in the internal focus condition (mean difference: 26.4°, 95% CI [20.6, 32.3]; p < 0.001, d = 1.24). However, there was a difference favouring the internal focus condition for flexion-extension (mean difference: 8.2°, 95% CI [-14.9, -1.5]; p = 0.018, d = 0.33). The variability in ROM was not explained by variability in fear of movement (for all correlations p ≥ 0.197).

CONCLUSION

An external focus resulted in a larger range of rotation, but our flexion-extension findings suggest that the task has to be specific to elicit such an effect. Further research, using a task that sufficiently elicits movement in all directions, is needed to determine the value of an external focus during exercise.

The effects of internal representations on performance and fluidity in a motor task

Individuals can differ in the mode in which they experience conscious thought. These differences in visualisation and verbalisation can also be evident during motor control. The Internal Representation Questionnaire (IRQ) was developed to measure propensity to engage certain types of representations, but its ability to predict motor control and links to reinvestment and motor imagery have not been tested. 159 included participants completed the IRQ, movement specific reinvestment scale (MSRS), and a novel online motor task before and after a period of practice. Results showed that the IRQ Verbal and Orthographic factors were significant predictors of scores on the MSRS. The IRQ factor of Manipulational Representations predicted motor performance both before and after practice. The fluidity of executed movements were predicted by the IRQ verbalisation factor where higher propensity to verbalise was associated with higher levels of jitter, but only after a period of practice. Results suggest there may be some informative conceptual overlap between internal verbalisations and reinvestment and that the propensity to manipulate internal representations may be predictive of motor performance in new tasks. The IRQ has potential to be a valuable tool for predicting motor performance.

Perceptions of learning and teaching human movement in physiotherapy: A systematic review and metasynthesis of qualitative studies

PURPOSE

Human movement is essential for health and well-being. Understanding human movement is pivotal in physiotherapy, but also an important element of physiotherapy education. This review identified, critically appraised, and synthesized the available evidence on learning and teaching human movement in physiotherapy as perceived by students, therapists, and instructors.

METHODS

The databases MEDLINE, CINAHL, ERIC, PsycINFO, MEDIC and FINNA, were searched. The search was conducted in March/April 2020 and updated in March 2022. The systematic review followed the JBI methodology for systematic reviews of qualitative evidence and was conducted in accordance with an a priori protocol.

RESULTS

The overall quality of the 17 included studies was scored low on ConQual but dependability and credibility were rated as moderate. Four synthesized findings aggregated from 17 categories and 147 findings described the perceived significance of 1) being present in movement, 2) movement quality, 3) movement transfer, and 4) contextual factors for the learning or teaching of human movement in physiotherapy.

CONCLUSION

The synthesized findings indicate that the perceived significance of contextual factors, movement quality and transfer, and being present in movement should be considered in all learning and teaching of movement in physiotherapy. However, the evidence of the review findings was evaluated as low-level, which should be considered when applying these results to physiotherapy education or practice.

Understanding implementation of a complex intervention in a stroke rehabilitation research trial: A qualitative evaluation using Normalisation Process Theory

BACKGROUND

The Implicit Learning in Stroke study was a pilot cluster randomised controlled trial, investigating the use of different motor learning strategies in acute stroke rehabilitation. Participating Stroke Units (n = 8) were from the South East/West regions of the UK, with the experimental intervention (implicit learning) being delivered by clinical teams. It required therapists to change how they gave instructions and feedback to patients during rehabilitation. This paper reports the processes underpinning implementation of the implicit learning intervention. The evaluation aimed to i) understand how therapists made sense of, engaged with and interpreted the effects of the intervention; ii) compare this to the experience reported by patients; iii) extrapolate learning of broader relevance to the design and conduct of research involving complex interventions in stroke rehabilitation.

METHODS

Qualitative evaluation, with data collected through focus groups with clinical staff (n = 20) and semi structured interviews with people with stroke (n = 19). Mixed inductive and theory driven analysis, underpinned by Normalisation Process Theory.

RESULTS

How therapists made sense of and experienced the intervention impacted how it was implemented. The intervention was delivered by individual therapists, and was influenced by their individual values, beliefs and concerns. However, how teams worked together to build a shared (team) understanding, also played a key role. Teams with a more "flexible" interpretation, reported the view that the intervention could have benefits in a wide range of scenarios. Those with a more fixed, "rule based" interpretation, found it harder to implement, and perceived the benefits to be more limited. Therapists' concerns that the intervention may impair therapeutic relationships and patient learning were not reflected in how patients experienced it.

CONCLUSIONS

Changing practice, whether in a research study or in the "real world", is complex. Understanding the process of implementation is crucial to effective research delivery. Implementation frameworks facilitate understanding, and subsequently the systematic and iterative development of strategies for this to be addressed. How teams (rather than individuals) work together is central to how complex interventions are understood and implemented. It is possible that new complex interventions work best in contexts where there are 'flexible' cultures. Researchers should consider, and potentially measure this, before they can effectively implement and evaluate an intervention.

TRIAL REGISTRATION

Clinical Trials - NCT03792126.

Principles into Practice: An Observational Study of Physiotherapists use of Motor Learning Principles in Stroke Rehabilitation

OBJECTIVE(S)

To describe a) how motor learning principles are applied during post stroke physiotherapy, with a focus on lower limb rehabilitation; and b) the context in which these principles are used, in relation to patient and/or task characteristics.

DESIGN

Direct non-participation observation of routine physiotherapy sessions, with data collected via video recording. A structured analysis matrix and pre-agreed definitions were used to identify, count and record: type of activity; repetitions; instructional and feedback statements (frequency and type); strategies such as observational learning and augmented feedback. Data was visualised using scatter plots, and analysed descriptively.

SETTING

6 UK Stroke Units PARTICIPANTS: 89 therapy sessions were observed, involving 55 clinicians and 57 patients.

RESULTS

Proportion of time spent active within each session ranged from 26% to 98% (mean 85, SD 19). The frequency of task repetition varied widely, with a median of 3.7 repetitions per minute (IQR 2.1-8.6). Coaching statements were common (mean 6.46 per minute), with 52% categorised as instructions, 14% as feedback, and 34% as verbal cues/motivational statements. 13% of instructions and 6% of feedback statements were externally focussed. Examining the use of different coaching behaviours in relation to patient characteristics found no associations. Overall, practice varied widely across the dataset.

CONCLUSIONS

To optimise the potential for motor skill learning, therapists must manipulate features of their coaching language (what they say, how much and when) and practice design (type, number, difficulty and variability of task). There is an opportunity to implement motor learning principles more consistently, to benefit motor skill recovery following stroke.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03792126). CONTRIBUTION OF THE PAPER.

Attentional Focus Strategies to Improve Motor Performance in Older Adults: A Systematic Review

Previous literature shows the beneficial effects of an external focus of attention on various sports skills in young adults. The objective of this systematic review is to evaluate the effects of external and internal focus of attention on motor performance in healthy older adults. The literature search was conducted in five electronic databases (PsycINFO, PubMed, SPORTDiscus, Scopus, and Web of Science). Eighteen studies that met the inclusion criteria were evaluated. Most of the motor tasks targeting older adults were related to postural control and gait. Over 60% of the included studies reported that the effect of an external focus was superior to that of an internal focus on motor performance in older adults. An external focus generally results in better motor performance than an internal focus among healthy older adults. However, the advantage of an external focus on locomotion may not be as significant as those illustrated in previous attentional focus studies. A challenging cognitive task may allow more automatic motor control than an external focus. Practitioners might provide clear instruction cues guiding performers to divert their attention away from their body and towards the movement effect for better performance, particularly in balancing tasks.

Integrating Transcranial Direct Current Stimulation into an Existing Inpatient Physiotherapy Program to Enhance Motor Learning in an Adolescent with Traumatic Brain Injury: A Case Report

PURPOSE

Describe how transcranial direct current stimulation (tDCS) was incorporated into an inpatient physiotherapy program for an adolescent with severe traumatic brain injury (TBI), detail the motor learning focus of the physiotherapy sessions, and summarize gross motor progress.

METHOD

This case report describes an adolescent who received 20 minutes of anodal tDCS immediately prior to 16 physiotherapy sessions over four weeks. Potential side effects were tracked pre/post tDCS. Gross motor outcomes were measured pre-intervention, post-intervention, and three months post-intervention. Physiotherapy session content was analyzed using therapist documentation and the Motor Learning Strategies Rating Instrument.

RESULTS

The youth tolerated tDCS well. The primary side effect was itchiness under the electrodes during tDCS sessions. His mobility progressed from wheelchair use pre- 'tDCS + physiotherapy' to ambulation with a walker post-intervention. His Gross Motor Function Measure score increased 33.1% points pre/post intervention. Session tasks often had several foci (e.g., skill acquisition, strength, and balance) with task focus changing as the youth progressed. Various motor learning strategies were layered within tasks to support performance and learning.

CONCLUSIONS

tDCS was successfully integrated into an existing inpatient physiotherapy program for an adolescent with TBI. This protocol provides a structure for implementing, monitoring, and measuring tDCS + physiotherapy in pediatric rehabilitation.

The Path to Translating Focus of Attention Research Into Canadian Physiotherapy, Part 1: Physiotherapists’ Self-Reported Focus of Attention Use Via a Study-Specific Questionnaire

The focus of attention literature has shown robust findings for the benefits of providing statements that focus on the movement effect or outcome (external focus of attention [EFOA]) as opposed to focusing on the movement kinematics (internal focus of attention). Observational studies, however, have revealed that physiotherapists use fewer EFOA statements than internal focus of attention statements in their practice. Most evidence in this regard has been from non-Canadian physiotherapists working in stroke rehabilitation; consequently, we sought to examine whether Canadian physiotherapists working with various rehabilitation populations also use EFOA statements to a lesser extent than internal focus of attention statements. The “Therapists’ Perceptions of Motor Learning Principles Questionnaire (TPMLPQ)” was thus designed and data from 121 Canadian physiotherapists showed low relative frequencies of EFOA use (31.3% ± 14%) averaged across six hypothetical scenarios. A higher EFOA was reported, however, for two of the six scenarios: a functional reaching scenario (55.5% ± 37.0%) and pelvic floor task (65.6% ±32.9%). This data suggest that the findings of EFOA benefits have not been widely translated into Canadian physiotherapy settings; furthermore, the findings of the scenario-dependency warrant future investigation into factors, such as task characteristics, that may influence physiotherapists’ FOA use.

Development of lower limb training interventions that promote an external focus of attention in people with stroke: a modified Delphi survey

OBJECTIVE

To produce guidance and validated examples of tasks that promote an external focus of attention, for use in lower limb rehabilitation in an inpatient stroke care setting.

DESIGN

Electronic survey, using e-Delphi methodology.

PARTICIPANTS

A multi-professional expert panel of 14 clinicians and researchers, with expertise in stroke rehabilitation and/or motor learning.

METHOD

Each survey round consisted of two parts: 1) classification of specific exercise examples, shown using video and 2) the categorization of specific tratement adjuncts. The panel was asked to comment on: likely focus of attention of the performer; instructions that would promote an external focus of attention; and how the task set-up could be modified to promote an external focus of attention. Rounds 2 and 3 included a summary of results from the previous round, and revised/new examples. The panel were also asked to state their level of agreement with a series of statements that arose from the free text. Three rounds of survey were completed and the a priori threshold for agreement was set at 80%.

RESULTS

Eighteen iterations of exercises were presented, and 12 were accepted as promoting an external focus of attention. In addition, six additional statements were generated based on open responses, leading to further specific guidance on facilitating an external focus of attention in clinical practice.

CONCLUSIONS

Commonly used rehabilitation exercises can be adapted to promote an external focus of attention, by altering the therapist's use of instructions and/or altering the task set up. Treatment principles and examples of tasks that promote an external focus have been produced.

The Arrival of the Metaverse in Neurorehabilitation: Fact, Fake or Vision?

The metaverse is a new technology thought to provide a deeper, persistent, immersive 3D experience combining multiple different virtual approaches in a full continuum of physical–digital interaction spaces. Different from virtual reality (VR) and augmented reality (AR), the metaverse has a service-oriented solid model with an emphasis on social and content dimensions. It has widely been demonstrated that motor or cognitive deficits can be more effectively treated using VR/AR tools, but there are several issues that limit the real potential of immersive technologies applied to neurological patients. In this scoping review, we propose future research directions for applying technologies extracted from the metaverse in clinical neurorehabilitation. The multisensorial properties of the metaverse will boost the embodied cognition experience, thus influencing the internal body representations as well as learning strategies. Moreover, the immersive social environment shared with other patients will contribute to recovering social and psychoemotional abilities. In addition to the many potential pros, we will also discuss the cons, providing readers with the available information to better understand the complexity and limitations of the metaverse, which could be considered the future of neurorehabilitation.

Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss

OBJECTIVE

Adopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting.

METHODS

Twenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4-21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users' age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received.

RESULTS

We recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively).

CONCLUSIONS

Our results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users' body movements and not externally on the movement effects.

IMPACT STATEMENT

While more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.

Attentional focus effect on dual-task walking in Parkinson's disease with and without freezing of gait

In Parkinson's disease, the optimal attentional focus strategy for dual-task walking may vary with freezing of gait (FOG), due to different severities of impaired automaticity. The study aimed to investigate (i) the immediate effect of attentional focus on dual-task walking in participants with and without FOG, and (ii) the training effect of attentional focus on walking, FOG, and falls. In experiment 1, FOG and non-FOG groups (16 participants each) performed a dual-task of holding two interlocking rings apart while walking, either without attention instruction or with instructions to focus attention internally or externally. Gait parameters and ring-touching times were measured. In experiment 2, 30 participants with FOG were randomized to 6 weeks of dual-task training with internal-focus or external-focus instruction. Before and after training, we recorded timed up-and-go (TUG) and TUG dual-task (TUGdt) in on-medication and off-medication states, and the numbers of FOG episodes and falls. The non-FOG group showed less step length variability and shorter ring-touching times with external-focus. The FOG group showed less step length variability, less cadence, increased gait velocity, and longer step lengths with internal-focus compared to external-focus and no-focus instructions. Both internal-focus and external-focus training reduced FOG and falls after intervention, but only internal-focus training reduced TUG and TUGdt in both on-medication and off-medication states. Our findings suggest external-focus would enhance walking automaticity and the concurrent task accuracy for non-freezers, whereas for freezers, internal-focus could increase gait stability and lead to a more positive effect on improving locomotion control and reducing falling risk.

Pay attention! The influence of coach-, content-, and player-related factors on focus of attention statements during tennis training

It is well established that adopting an external focus of attention (EF) enhances motor learning when contrasted to an internal focus (IF) or a neutral condition. Despite consistent evidence for this performance-enhancing effect of an EF, recent studies show that coaches predominantly induce an IF in the communication with athletes. It remains, however, unknown whether and to what degree coach-, content- or player-related factors have an impact on the focus of attention during youth tennis training. Therefore, we recorded all statements from 10 tennis coaches during six training sessions with a total of 87 youth athletes aged 18 years or younger. All statements were categorized according to the focus they induced (IF, EF, neutral, best place to hit the ball, mix, no focus) and the form of communication (instruction, feedback). Of the relevant statements (n=3049), 45.1% promoted an EF, whereas 33.1% induced an IF. Evaluation of coaches-, player- and content-specific features (education, age of coach/player, training content, skill level) showed that more statements with an IF were given when training beginners. The data also show more statements with an EF for instructions (59.0%) compared to feedback (43.0%). Our results contrast with other sports where instructions with an IF predominate. Thus, instrumented sports with external targets (e.g. tennis) might be better suited for inducing an EF. The data also show that coaches are more likely to use IF when communicating with beginners. Consequently, an EF should not be induced in every possible situation, even if this is often communicated so far.

Effective Attentional Focus Strategies after Anterior Cruciate Ligament Reconstruction: A Commentary

Individuals after anterior cruciate ligament reconstruction (ACLR) have a high rate of reinjury upon return to competitive sports. Deficits in motor control may influence reinjury risk and can be addressed during rehabilitation with motor learning strategies. When instructing patients in performing motor tasks after ACLR, an external focus of attention directed to the intended movement effect has been shown to be more effective in reducing reinjury risk than an internal focus of attention on body movements. While this concept is mostly agreed upon, recent literature has made it clear that the interpretation and implementation of an external focus of attention within ACLR rehabilitation needs to be better described. The purpose of this commentary is to provide a clinical framework for the application of attentional focus strategies and guide clinicians towards effectively utilizing an external focus of attention in rehabilitation after ACLR.

LEVEL OF EVIDENCE

5.

Development of a vibrotactile cueing device that implicitly increases walking speed during gait training in stroke patients: an observational case series study

One of the main sequelae of stroke is difficulty walking, which is characterised by decreased walking speed and asymmetrical walking patterns. Physical therapists often rely on explicit motor learning strategies, i.e., providing mainly verbal instructions for how movements should be performed. However, the voluntary movement induced by explicit instruction may lead to associated unintended muscle contractions or higher cognitive demand, which could be detrimental. We introduce a vibrotactile cueing device that implicitly improves walking speed. The stroke patient walks while alternating vibrational cues are given to the left and right sides of their waist. At each specified step, cueing frequency increases in the cueing group without the patient's awareness. The four patients in the cueing group did not notice the increase in walking speed during training; however, we observed an improvement in walking speed and cadence in patients using the proposed cueing system, which was maintained during the posttest phase. Additionally, patients using the cueing system were able to suppress excessive compensatory movements during training compared with patients who did not use the system. This case series study indicates that the proposed system for gait rehabilitation of stroke patients can enable an increase in walking speed without excessive effort.

Neuromuscular training programs predominantly include instructions that promote an internal focus

Neuromuscular training programs that include movement pattern retraining and strengthening, plyometric, and balance exercises are recommended for anterior cruciate ligament injury prevention. Recent evidence suggests that the effectiveness of these programs may be enhanced when athletes train with an external focus; however, clinicians typically rely predominantly on instructions encouraging an internal focus. The aim of this study was to examine the types of instructions provided as part of popular neuromuscular training programs used for anterior cruciate ligament injury prevention. The technique-related instructions provided as part of the FIFA 11+, HarmoKnee, Knakontroll, and Prevent Injury and Enhance Performance programs were categorized as either promoting an internal focus or an external focus. Instructions provided during movement pattern retraining tasks and strengthening, plyometric, and balance training exercises were specifically examined. Next, the percentage of technique-related instructions that promoted an internal focus, versus the percentage that promoted an external focus, were compared for the various program components. Across all programs examined, the vast majority of technique-related instructions for the movement pattern re-training tasks (≥83.3%) and the strengthening, balance, and plyometric exercises (≥75.0%) appeared to promote an internal focus. Despite evidence suggesting that the effectiveness of neuromuscular training programs may be enhanced by encouraging an external focus, most technique-related instructions provided as part of popular neuromuscular training programs appear to promote an internal focus. Modifying neuromuscular training programs to promote a more external focus could help to improve the effectiveness of these programs for anterior cruciate ligament injury prevention.

Effect of Bench Press Load Knowledge on One Repetition Maximum Strength

ABSTRACT

Snarr, RL, Adams, K, and Cook, J. Effect of bench press load knowledge on one repetition maximum strength. J Strength Cond Res 35(8): 2121-2126, 2021-Knowledge of a given load and visual feedback are crucial while performing a given task. Although previous literature has examined the consequences of lifting a submaximal weight, the removal of load knowledge has yet to be examined under maximal effort. Therefore, the purpose of this investigation was to examine the differences in 1 repetition maximum (1RM) bench press values between a known and unknown external load. Twenty resistance-trained subjects (10 male subjects and 10 female subjects) completed 2 trials of a 1RM bench press protocol separated by 48-72 hours. The two 1RM trials consisted of (a) a traditional 1RM lift in which subjects could see the external load and (b) a 1RM lift in which the external load was blocked from view of the subject. Trials were randomized for all subjects. Results indicated that no differences were observed when the load was known vs. unknown within all subjects (p = 0.094; Cohen's d = 0.03; intraclass correlation coefficient = 0.99). In addition, 40% decreased and 15% increased their 1RM, despite the unknown condition. A statistical difference was found between the initial 1RM estimation vs. measured 1RM during the known load trial (p = 0.034, Cohen's d = 0.07). Practitioners should note that load knowledge before a maximal lift does not appear to present any significant detrimental effects on performance. Therefore, training during a "blinded" condition may present a unique modality and additional balance component that would not be presented during a traditional maximal lift. Further examination of attentional focus and muscle activation differences are warranted.

Rupture, reconstruction, and rehabilitation: A multi-disciplinary review of mechanisms for central nervous system adaptations following anterior cruciate ligament injury

BACKGROUND

Despite surgical reconstruction and extensive rehabilitation, persistent quadriceps inhibition, gait asymmetry, and functional impairment remain prevalent in patients after anterior cruciate ligament (ACL) injury. A combination of reports have suggested underlying central nervous system adaptations in those after injury govern long-term neuromuscular impairments. The classic assumption has been to attribute neurophysiologic deficits to components of injury, but other factors across the continuum of care (e.g. surgery, perioperative analgesia, and rehabilitative strategies) have been largely overlooked.

OBJECTIVE

This review provides a multidisciplinary perspective to 1) provide a narrative review of studies reporting neuroplasticity following ACL injury in order to inform clinicians of the current state of literature and 2) provide a mechanistic framework of neurophysiologic deficits with potential clinical implications across all phases of injury and recovery (injury, surgery, and rehabilitation) RESULTS: Studies using a variety of neurophysiologic modalities have demonstrated peripheral and central nervous system adaptations in those with prior ACL injury. Longitudinal investigations suggest neurophysiologic changes at spinal-reflexive and corticospinal pathways follow a unique timecourse across injury, surgery, and rehabilitation.

CONCLUSION

Clinicians should consider the unique injury, surgery, anesthesia, and rehabilitation on central nervous system adaptations. Therapeutic strategies across the continuum of care may be beneficial to mitigate maladaptive neuroplasticity in those after ACL injury.

Targeted verbal cues can immediately alter gait following stroke

Background: Physical therapists use verbal cueing extensively during gait rehabilitation. Nevertheless, little is known about the ability of individuals post-stroke to make immediate changes to targeted spatiotemporal gait parameters from verbal commands. Additionally, adequate muscle strength may be necessary to promote positive alterations in gait.Objectives: To determine the influence of targeted verbal cues on spatiotemporal gait parameters for individuals with chronic stroke. Further, we assessed the potential of a relationship between cue-induced gait modifications and paretic lower limb strength.Methods: Using a within-subjects design, twenty-seven adults with chronic stroke walked over a pressure mat with verbal cues to walk at (1) comfortable and (2) fast speeds, with increased (3) arm swing, (4) foot height, (5) step length, (6) push off, and (7) cadence. We also assessed lower extremity strength using a hand-held dynamometer. We measured gait speed, step length, stance time, and cadence for comparisons between conditions and performed correlational analyses to assess the influence of strength on gait alterations.Results: Specific cues elicited increased walking speed, cadence, step lengths and paretic limb stance time. Only greater paretic hip and knee flexion strength was related to the ability to increase cadence when cued to do so (r > 0.41).Conclusion: With targeted verbal cueing, clinicians can improve step length, gait speed, stance time and cadence for individuals with chronic stroke. Lower extremity strength does not appear to be related to the ability to alter gait with verbal cueing in individuals with chronic stroke.

Implicit and Explicit Motor Learning Interventions Have Similar Effects on Walking Speed in People After Stroke: A Randomized Controlled Trial

OBJECTIVE

Clinicians may use implicit or explicit motor learning approaches to facilitate motor learning of patients with stroke. Implicit motor learning approaches have shown promising results in healthy populations. The purpose of this study was to assess whether an implicit motor learning walking intervention is more effective compared with an explicit motor learning walking intervention delivered at home regarding walking speed in people after stroke in the chronic phase of recovery.

METHODS

This randomized, controlled, single-blind trial was conducted in the home environment. The 79 participants, who were in the chronic phase after stroke (age = 66.4 [SD = 11.0] years; time poststroke = 70.1 [SD = 64.3] months; walking speed = 0.7 [SD = 0.3] m/s; Berg Balance Scale score = 44.5 [SD = 9.5]), were randomly assigned to an implicit (n = 38) or explicit (n = 41) group. Analogy learning was used as the implicit motor learning walking intervention, whereas the explicit motor learning walking intervention consisted of detailed verbal instructions. Both groups received 9 training sessions (30 minutes each), for a period of 3 weeks, targeted at improving quality of walking. The primary outcome was walking speed measured by the 10-Meter Walk Test at a comfortable walking pace. Outcomes were assessed at baseline, immediately after intervention, and 1 month postintervention.

RESULTS

No statistically or clinically relevant differences between groups were obtained postintervention (between-group difference was estimated at 0.02 m/s [95% CI = -0.04 to 0.08] and at follow-up (between-group difference estimated at -0.02 m/s [95% CI = -0.09 to 0.05]).

CONCLUSION

Implicit motor learning was not superior to explicit motor learning to improve walking speed in people after stroke in the chronic phase of recovery.

IMPACT

To our knowledge, this is the first study to examine the effects of implicit compared with explicit motor learning on a functional task in people after stroke. Results indicate that physical therapists can use (tailored) implicit and explicit motor learning strategies to improve walking speed in people after stroke who are in the chronic phase of recovery.

Visual Perturbation to Enhance Return to Sport Rehabilitation after Anterior Cruciate Ligament Injury: A Clinical Commentary

Anterior cruciate ligament (ACL) tears are common traumatic knee injuries causing joint instability, quadriceps muscle weakness and impaired motor coordination. The neuromuscular consequences of injury are not limited to the joint and surrounding musculature, but may modulate central nervous system reorganization. Neuroimaging data suggest patients with ACL injuries may require greater levels of visual-motor and neurocognitive processing activity to sustain lower limb control relative to healthy matched counterparts. Therapy currently fails to adequately address these nuanced consequences of ACL injury, which likely contributes to impaired neuromuscular control when visually or cognitively challenged and high rates of re-injury. This gap in rehabilitation may be filled by visual perturbation training, which may reweight sensory neural processing toward proprioception and reduce the dependency on vision to perform lower extremity motor tasks and/or increase visuomotor processing efficiency. This clinical commentary details a novel approach to supplement the current standard of care for ACL injury by incorporating stroboscopic glasses with key motor learning principles customized to target visual and cognitive dependence for motor control after ACL injury.

LEVEL OF EVIDENCE

5.

Effects of attentional focus on upper extremity motor performance in post stroke patients: A randomized pilot study

INTRODUCTION

To facilitate the command to the learner, therapist can use verbal cues for guidance: internal focus (own body) and external focus (consequence of movement in the environment).

OBJECTIVE

To examine the effects of different attentional focus on upper limb motor performance in post-stroke.

METHODS

Randomized controlled trial with 2 groups. Study realized at Integrated Clinic of the Faculty of Health Science at Trairi (Santa Cruz, Rio Grande do Norte, Brazil). Twelve participants allocated into 2 groups. Two motor tasks were used: task 1, reach-point; task 2, reach-grasp-fit, with the paretic extremity, using verbal commands directed by a trained therapist. In the first phase, Group 1 received commands with internal focus, while Group 2 was instructed with commands with external focus. After 1 week, the command type was changed between groups. The variables collected was movement time, velocity and number of peaks velocity.

RESULTS

Both attentional focus promoted significant differences in movement time and velocity, however, only Internal Focus provided significant results in both tasks of the same variables.

DISCUSSION

The benefits of 1 attentional focus on the other are not fully confirmed. However, not receiving any kind of attention guidance compromises motor performance. The results support the hypothesis that the benefits of the External Focus are accentuated when preceded by the Internal Focus.

CLINICAL TRIAL REGISTRATION

Research Ethics Committee of the Faculty of Helth Science at Trairi (Facisa - UFRN)- Number CAAE 2.625.609, approved on April 13, 2018; Brazilian Registry of Clinical Trials - RBR-4995cr approved on July 4, 2019 retrospectively registered (http://www.ensaiosclinicos.gov.br/rg/RBR-4995cr/).

Testing a new active learning approach to advance motor learning knowledge and self-efficacy in physical therapy undergraduate education

BACKGROUND

Motor learning (ML) science is foundational for physical therapy. However, multiple sources of evidence have indicated a science-practice gap. Clinicians report low self-efficacy with ML concepts and indicate that the lack of access to systematic training is a barrier for practical implementation. The general goal of this preliminary study was to describe the effects of a new educational intervention on physical therapy student's ML self-efficacy and knowledge.

METHODS

Self-efficacy was assessed with the Physical Therapists' Perceptions of Motor Learning questionnaire. Data was acquired from third-semester students before their participation in the ML educational intervention. Reference self-efficacy data was also acquired from physical therapy professionals and first and last-semester students. The educational intervention for third-semester students was designed around an established framework to apply ML principles to rehabilitation. A direct experience, the "Learning by Doing" approach, in which students had to choose a motor skill to acquire over 10 weeks, provided the opportunity to apply ML theory to practice in a personally meaningful way. After the intervention self-efficacy was re-tested. ML knowledge was tested with an objective final exam. Content analysis of coursework material was used to determine how students comprehended ML theory and related it to their practical experience. The Kruskal-Wallis and Mann-Whitney U tests were used to compare self-efficacy scores between the four groups. Changes in self-efficacy after the educational intervention were analyzed with the Wilcoxon test. Spearman rank correlation analysis was used to test the association between self-efficacy and final exam grades.

RESULTS

By the end of the intervention, students' self-efficacy had significantly increased (p < 0.03), was higher than that of senior students (p < 0.00) and experienced professionals (p < 0.00) and correlated with performance on an objective knowledge test (p < 0.03). Content analysis revealed that students learned to apply the elements of ML-based interventions present in the scientific literature to a real-life, structured ML program tailored to personal objectives.

CONCLUSIONS

Positive improvements were observed after the intervention. These results need confirmation with a controlled study. Because self-efficacy mediates the clinical application of knowledge and skills, systematic, active training in ML may help reduce the science-practice gap.

Using Virtual Reality as a Tool in the Rehabilitation of Movement Abnormalities in Schizophrenia

Movement abnormalities are prevalent across all stages of schizophrenia contributing to poor social functioning and reduced quality of life. To date, treatments are scarce, often involving pharmacological agents, but none have been shown to improve movement abnormalities effectively. Virtual reality (VR) is a tool used to simulate virtual environments where behavioral performance can be quantified safely across different tasks while exerting control over stimulus delivery, feedback and measurement in real time. Sensory information is transmitted via a head mounted display allowing users to directly interact with virtual objects and bodies using gestures and body movements in the real world to perform different actions, permitting a sense of immersion in the simulated virtual environment. Although, VR has been widely used for successful motor rehabilitation in a variety of different neurological domains, none have been exploited for motor rehabilitation in schizophrenia. The objectives of this article are to review movement abnormalities specific to schizophrenia, and how VR can be utilized to restore and improve motor functioning in patients with schizophrenia. Constructing VR-mediated motor-cognitive interventions that can help in retaining and transferring the learned outcomes to real life are also discussed.

Lower extremity prism adaptation in individuals with anterior cruciate ligament reconstruction

BACKGROUND

Emerging research has proposed a growing reliance on visual processing during motor performance in individuals following anterior cruciate ligament reconstruction. Reconstructed individuals display increased activation of visual processing areas during task execution and exhibit dramatic performance decrements when vision is completely removed, however the effect of visual information manipulation on performance remains unknown. The purpose of this study was to determine how manipulation of visual information changes performance in persons with anterior cruciate ligament reconstruction.

METHODS

Twenty-one persons with anterior cruciate ligament reconstruction and 21 matched healthy adults reached to a target with the toe of the involved limb 50 times while wearing prism goggles that vertically shifted their visual field. Toe kinematics were collected to quantify endpoint error and reaching behavior.

FINDINGS

Statistical analyses failed to detect significant differences, evidencing both groups performed similarly with respect to endpoint error, movement duration, peak and maximum endpoint velocities, and initial direction error.

INTERPRETATION

When provided inaccurate information via a visual field perturbation, both groups demonstrated comparable adaptation and post-adaptation behavior. These results suggest this sample of persons with anterior cruciate ligament reconstruction are able to effectively integrate information across sensory systems as well as non-injured individuals.

Verbal feedback enhances motor learning during post-stroke gait retraining

BACKGROUND

Fast treadmill walking combined with functional electrical stimulation to ankle muscles (FastFES) is a well-studied gait intervention that improves post-stroke walking function. Although individualized verbal feedback is commonly incorporated during clinical gait training, and a variable practice structure is posited to enhance learning, the influence of these two factors on motor learning during locomotor interventions such as FastFES is poorly understood.

OBJECTIVES

To determine if the addition of individualized verbal feedback or variable practice to a FastFES training session enhances motor learning of targeted gait patterns.

METHODS

Nine individuals with post-stroke hemiparesis completed a crossover study comprising exposure to 3 dose-matched types of gait training: (1) FastFES (FF), comprising five 6-minute bouts of training with intermittent FES, (2) FF with addition of individualized verbal instructions and faded feedback delivered by a physical therapist (FF+PT), (3) FF with variable gait speed and FES timing (FF+Var). Gait biomechanics data were collected before (Pre), immediately after (Post), and 24-h following (Retention) each training type. Within-session and retention change scores of 3 targeted gait variables were calculated to assess locomotor learning.

RESULTS

FF+PT resulted in larger improvements within-session and at retention in trailing limb angle, and a trend for larger improvements in paretic pushoff compared to FF. FF+Var failed to show greater learning of biomechanical variables compared to FF.

CONCLUSIONS

Addition of individualized verbal feedback (FF+PT) to a single session of gait training may enhance within- and across-session learning of targeted gait variables in people post-stroke, and merits more investigation.

Gait Stability in Older Adults During Level-Ground Walking: The Attentional Focus Approach

OBJECTIVES

The objective of this study was to investigate the effect of attentional focus instructions on gait stability during level-ground walking among older adults.

METHODS

We recruited 140 community-dwelling older adults (mean age = 70.3 years, SD = 4.7 years) from elderly community centers in Hong Kong. The experiment included assessments on participant's characteristics and walking trials. During walking trials, each participant was invited to walk at a self-selected pace along a 6-m walkway. Internal focus instructions (Internal condition), external focus instructions (External condition), or no instruction (Control condition) were given in a randomized order for three trials per condition, giving a total of nine walking trials. Spatial and temporal gait parameters were measured.

RESULTS

Results showed significantly higher body sway and variability of swing and stance time under Internal condition relative to External and Control conditions. Moreover, reduced velocity and shorter steps were demonstrated under Internal condition relative to External and Control conditions.

DISCUSSION

External focus instructions did not improve gait stability in older adults when compared to Control condition. Internal focus instructions appear to compromise gait stability. Future research should investigate if walking instructions that refer to body movements explicitly compromise gait rehabilitation for older adults in clinical settings.

The Effects of Attentional Focus Instructions Specific to Body Movements on Movement Quality and Performance

Contexts: Directing an individual's attention to the effect of the movements (external focus) has been shown to improve performance than directing attention to body movements (internal focus). However, the effect of attentional focus instructions specific to movement quality has not been investigated thoroughly.

OBJECTIVE

To compare the effects of internal and external focus instructions specific to body movements.

DESIGN

Mixed design, 2 (sex) × 2 (instructions).

SETTINGS

Laboratory setting.

PARTICIPANTS

A total of 40 participants (males, n = 20; mean [SD]; age = 22.0 [2.19] y; height = 179.33 [5.90] cm; mass = 77.7 [13.04] kg; females, n = 20; age = 22.0 [3.87] y; height = 164.84 [5.80] cm; mass = 71.48 [20.66] kg) were recruited.

INTERVENTION

Participants completed 2 consecutive jumps (ie, a forward jump from a height and then a maximal vertical jump) with internal focus and external focus instructions. External focus was elicited by placing pieces of tape on the participants' legs.

MAIN OUTCOME MEASURES

Landing quality was measured by the Landing Error Scoring System to assess movement quality, and the vertical jump height was measured by Vertec.

RESULTS

The performance results showed that the external focus condition resulted in superior vertical jump height compared with the internal focus condition (P < .05). Although landing quality did not show significant differences between 2 conditions, the effect size (η2 = .09) indicated that landing quality was better when participants adopted an external, rather than an internal focus of attention (P = .07).

CONCLUSIONS

The body-oriented instructions can be provided externally by adding artificial external cues and directing attention to them. Importantly, the findings were evident in a qualitative assessment that can be adopted by practitioners. The results suggest that practitioners should adopt an external focus cue for performance and also consider using an external focus for movement quality.

Verbal Instruction Reduces Patellofemoral Joint Loading During Bodyweight Squatting

Context: The bodyweight squat exercise is a common component for treatment and prevention of patellofemoral pain; however, it can also place a high load on the patellofemoral joint. Restricting anterior motion of the knees relative to the toes during squatting appears to reduce patellofemoral loading. However, exercise professionals typically rely on verbal instructions to alter squat technique. Objective: To evaluate the influence of verbal instructions regarding squat technique on patellofemoral joint loading. Design: Cross-sectional study. Setting: Motion analysis laboratory. Participants: Eleven uninjured females. Intervention: Participants performed bodyweight squats before (baseline) and after receiving verbal instructions to limit anterior knee motion. Two different types of verbal instruction were used, one intended to promote an internal focus of attention and the other intended to promote an external focus of attention. Three-dimensional kinematics and kinetics were recorded using a multicamera system and force plate. Main Outcome Measures: Sagittal plane patellofemoral joint forces and stress were estimated using a musculoskeletal model. Results: Participants demonstrated a reduction in patellofemoral joint forces (35.4 vs 31.3 N/kg; P = .01) and stress (10.7 vs 9.2 mPa; P = .002) after receiving instructions promoting an internal focus of attention, compared with their baseline trials. Participants also demonstrated a reduction in patellofemoral joint forces (35.4 vs 32.3 N/kg; P = .03) and stress (10.7 vs 9.6 mPa; P = .04) after receiving instructions promoting an external focus of attention (vs baseline). However, there were no significant differences in patellofemoral forces (P = .84) or stress (P = .41) for trials performed with an internal versus external attentional focus. Conclusion: It appears that verbal instruction regarding knee position influences patellofemoral joint loading during squatting.

Music Restores Propriospinal Excitation During Stroke Locomotion

Music-based therapy for rehabilitation induces neuromodulation at the brain level and improves the functional recovery. In line with this, musical rhythmicity improves post-stroke gait. Moreover, an external distractor also helps stroke patients to improve locomotion. We raised the question whether music with irregular tempo (arrhythmic music), and its possible influence on attention would induce neuromodulation and improve the post-stroke gait. We tested music-induced neuromodulation at the level of a propriospinal reflex, known to be particularly involved in the control of stabilized locomotion; after stroke, the reflex is enhanced on the hemiparetic side. The study was conducted in 12 post-stroke patients and 12 controls. Quadriceps EMG was conditioned by electrical stimulation of the common peroneal nerve, which produces a biphasic facilitation on EMG, reflecting the level of activity of the propriospinal reflex between ankle dorsiflexors and quadriceps (CPQ reflex). The CPQ reflex was tested during treadmill locomotion at the preferred speed of each individual, in 3 conditions randomly alternated: without music vs. 2 arrhythmic music tracks, including a pleasant melody and unpleasant aleatory electronic sounds (AES); biomechanical and physiological parameters were also investigated. The CPQ reflex was significantly larger in patients during walking without sound, compared to controls. During walking with music, irrespective of the theme, there was no more difference between groups. In controls, music had no influence on the size of CPQ reflex. In patients, CPQ reflex was significantly larger during walking without sound than when listening to the melody or AES. No significant differences have been revealed concerning the biomechanical and the physiological parameters in both groups. Arrhythmic music listening modulates the spinal excitability during post-stroke walking, restoring the CPQ reflex activity to normality. The plasticity was not accompanied by any clear improvement of gait parameters, but the patients reported to prefer walking with music than without. The role of music as external focus of attention is discussed. This study has shown that music can modulate propriospinal neural network particularly involved in the gait control during the first training session. It is speculated that repetition may help to consolidate plasticity and would contribute to gait recovery after stroke.

Timing and correction of stepping movements with a virtual reality avatar

Research into the ability to coordinate one's movements with external cues has focussed on the use of simple rhythmic, auditory and visual stimuli, or interpersonal coordination with another person. Coordinating movements with a virtual avatar has not been explored, in the context of responses to temporal cues. To determine whether cueing of movements using a virtual avatar is effective, people's ability to accurately coordinate with the stimuli needs to be investigated. Here we focus on temporal cues, as we know from timing studies that visual cues can be difficult to follow in the timing context. Real stepping movements were mapped onto an avatar using motion capture data. Healthy participants were then motion captured whilst stepping in time with the avatar's movements, as viewed through a virtual reality headset. The timing of one of the avatar step cycles was accelerated or decelerated by 15% to create a temporal perturbation, for which participants would need to correct to, in order to remain in time. Step onset times of participants relative to the corresponding step-onsets of the avatar were used to measure the timing errors (asynchronies) between them. Participants completed either a visual-only condition, or auditory-visual with footstep sounds included, at two stepping tempo conditions (Fast: 400ms interval, Slow: 800ms interval). Participants' asynchronies exhibited slow drift in the Visual-Only condition, but became stable in the Auditory-Visual condition. Moreover, we observed a clear corrective response to the phase perturbation in both the fast and slow tempo auditory-visual conditions. We conclude that an avatar's movements can be used to influence a person's own motion, but should include relevant auditory cues congruent with the movement to ensure a suitable level of entrainment is achieved. This approach has applications in physiotherapy, where virtual avatars present an opportunity to provide the guidance to assist patients in adhering to prescribed exercises.

The importance of different learning stages for motor sequence learning after stroke

The task of learning predefined sequences of interrelated motor actions is of everyday importance and has also strong clinical importance for regaining motor function after brain lesions. A solid understanding of sequence learning in stroke patients can help clinicians to optimize and individualize rehabilitation strategies. Moreover, to investigate the impact of a focal lesion on the ability to successfully perform motor sequence learning can enhance our comprehension of the underlying physiological principles of motor sequence learning. In this article, we will first provide an overview of current concepts related to motor sequence learning in healthy subjects with focus on the involved brain areas and their assumed functions according to the temporal stage model. Subsequently, we will consider the question of what we can learn from studies investigating motor sequence learning in stroke patients. We will first focus on the implications of lesion location. Then, we will analyze whether distinct lesion locations affect specific learning stages. Finally, we will discuss the implications for clinical rehabilitation and suggest directions for further research.

Physical therapists' perspectives of the construct of motor learning, and their motor learning-based practice: a qualitative study

Introduction: The perceptions and beliefs of physical therapists play an important role in their clinical behavior. These clinician-related aspects may contribute to the knowledge-action gap in the field of motor learning (ML). Accordingly, this study explored how a sample of physical therapists perceive ML in their practice.Methods: A qualitative phenomenological study was conducted. Twelve physical therapists with a wide range of work experience were purposefully selected. Data were collected through semi-structured interviews and analyzed using content analysis methodology. Themes and categories were identified.Results: We identified five key themes: 1) 'ML within the scope of PT' showed that participants perceived ML as a fundamental part of the profession; 2) 'Understanding of ML' showed that participants had difficulty understanding the field comprehensively; 3) 'Self-efficacy toward the topic of ML' revealed that participants had low self-efficacy about their knowledge of the topic; 4) 'Features of ML implementation' showed that physical therapists tended to implement ML intuitively; and 5) 'Barriers to implementation and ways to facilitate it' showed that lack of knowledge was perceived as a main barrier to implementation.Conclusions: Physical therapists' perceptions of and experiences with ML showed the complexity of the field and the lack of clarity regarding its theoretical content and clinical applications. There is a need to reinforce knowledge of ML among physical therapists at different levels of professional development and to promote self-efficacy toward its use, possibly by increasing ML knowledge and education while emphasizing its clinical context.

Comparing the Impact of an Implicit Learning Approach With Standard Care on Recovery of Mobility Following Stroke: Protocol for a Pilot Cluster Randomized Controlled Trial

BACKGROUND

Although implicit and explicit learning approaches have been well investigated in healthy populations, there is less evidence regarding the relative benefits of each approach in clinical practice. Studies in stroke typically investigate single elements of an implicit learning approach (ILA; eg, reduced quantity feedback or an external focus of attention) within controlled environments. These studies predominantly evaluate performance, with few measuring this over time (ie, learning). The relevance and transferability of current research evidence into stroke rehabilitation is therefore limited.

OBJECTIVE

The objective of this study was to compare the ILA with standard care in the acute phase following stroke, to generate data and insights to inform the design of a definitive trial, and to understand patient and therapist perceptions of the ILA.

METHODS

This is a multicenter, assessor-blind, cluster randomized controlled pilot trial with nested qualitative evaluation. Stroke units (clusters) will be randomized to either ILA (intervention) or standard care (control) arms. Therapy teams at the intervention sites will be trained in the ILA and provided with an intervention manual. Those at the control sites will have minimal input from the research team, other than for data collection. Consent will be provided at the individual participant level. Once enrolled, participants will receive rehabilitation that focuses on lower limb recovery, using the designated approach. Measures will be taken at baseline, every 2 weeks until the point of discharge from hospital, and at 3 months post stroke onset. Measures include the Fugl Meyer Assessment (motor leg subsection), modified Rivermead Mobility Index, Swedish Postural Adjustment in Stroke Scale, and achievement of mobility milestones. Fidelity of the treatment approach will be monitored using observational video analysis. Focus groups and interviews will be used to gain insight into the perceptions of trial participants and clinical teams.

RESULTS

The first site opened to recruitment in February 2019. The opening of a further 5 sites will be staggered throughout 2019. Results are expected in early 2021.

CONCLUSIONS

The findings from this mixed methods pilot study will be used to inform the design of a definitive study, comparing the ILA with standard care in acute stroke rehabilitation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03792126; https://clinicaltrials.gov/ct2/show/NCT03792126.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14222.

The effects of different attentional focus on poststroke gait

Attention may influence the motor performance of poststroke patients. The attentional focus implies “where” attention is focused while performing a specific movement. Focusing attention on the inside of the body while performing a specific exercise is called an internal focus (IF) and focus on the external environment is called an external focus (EF). This study examined the effect of attention on the gait of patients with chronic stroke. Sixteen subjects voluntarily participated in the study. The subjects were guided to walk while maintaining the required attentional focus, which is control, IF, and EF condition. Dependent variables were as follows: step length, stride length, step width, 10-m walk time, and weight distribution on the paretic limb. The results are as follows. First, the step length and the stride length were observed to be longer in the EF condition. Second, 10-m walk time was faster in EF condition. Third, under the EF condition, more weight was applied to the paretic limb. We suggest that EF instruction useful to improve the poststroke gait.

Impact of attentional focus on motor performance within the context of "early" limb regulation and "late" target control

Directing attention to the effect of one's movement (external focus) has been shown to aid performance compared to directing attention to the movement itself (internal focus). This finding has been predominantly explained by an external focus promoting action planning and automatic movement control, while an internal focus acts to constrain movement (constrained action hypothesis [CAH]). In a separate line of research, the multiple control process model states that early movement phases involve anticipated and feedforward processes, while late movement phases explicitly incorporate external afferent information. We hypothesized that enhanced planning and automatic movement control would manifest from an external/distal focus compared to internal/proximal focus. The present study had participants execute fast and accurate movements to a single target using a digitizing graphics tablet that translated movements to a screen. Participants were instructed to focus on the end target location (external-distal), movement of the cursor (external-proximal), and movement of the limb (internal-proximal). It was found that the external-distal focus generated a shorter time to initiate and execute movements (indicating enhanced movement planning) compared to the external- and internal-proximal conditions. In addition, only the external proximal focus revealed a reduction in spatial variability between peak velocity and movement end (indicating greater online control). These findings indicate that advances in action planning and online control occur when adopting an external-distal focus. However, there were some benefits to online control when adopting an external-proximal focus. We propose that an external-distal focus promotes action-effect principles, where there is a greater contribution of anticipatory feedforward processes that limit the need for late online control.

Motor Behavior Concepts in the Study of Balance: A Scoping Review

Previous research suggests that using Fitts' law; attentional focus or challenge point framework (CPF) is beneficial in balance control studies. A scoping review was conducted to examine studies that utilized these motor behavior concepts during balance control tasks. An extensive literature search was performed up to January 2018. Two independent reviewers conducted a study selection process followed by data extraction of the search results. Forty-six studies were identified, with 2 studies related to CPF, 12 studies related to Fitts' law and 32 studies related to focus of attention. The CPF appears to be a useful method for designing a progressive therapeutic program. Fitts' law can be used as a tool for controlling the difficulty of motor tasks. Focus of attention studies indicate that adopting an external focus of attention improves task performance. Overall, studies included in this review report benefit when using the selected motor behavior concepts. However, the majority (>80%) of studies included in the review involved healthy populations, with only three clinical trials. In order to ascertain the benefits of the selected motor behavior concepts in clinical settings, future research should focus on using these concepts for clinical trials to examine balance control among people with balance impairments.

Anticipatory postural adjustments during a Fitts' task: Comparing young versus older adults and the effects of different foci of attention

Anticipatory postural adjustments (APAs) are an integral part of standing balance. Previous research with balance control has shown that adopting an external focus of attention, compared to an internal focus of attention, yields better performance during motor skills. Despite the importance of APAs, especially among older adults, and the potential benefits of adopting an external focus of attention, studies investigating methods for improving APAs are limited. The aim of this study was to compare behavioral, kinematic and APAs measures while adopting different foci of attention among young and older adults when performing a lower extremity Fitts' task. Ten young adults (mean age 24 years ± 4.37) and ten older adults (mean age 75 years ± 5.85) performed a lower-extremity reaching task (Fitts' task) while adopting an external focus (focus on target) and an internal focus (focus on limb) in a within-subject design. A motion capture system was used to record participants' movement data. Custom software derived movement time (MT), peak velocity (PV), time to peak velocity (ttPV) and variability at target (SD_T). Electromyography (EMG) was used to determine APAs onset and magnitude. The findings showed that an external focus of attention led to significantly shorter MT, higher PV, shorter ttPV and more accuracy when reaching the target (SD_T) for both age groups. Also, EMG results showed that, with an external focus, APAs onset occurred earlier and APAs magnitude was more efficient. As predicted by Fitts' Law, participants spent more time executing movements to targets with higher indices of difficulty. Older adults compared to young adults were more adversely affected by the increase of difficulty of the Fitts' task, specifically, on measures of APAs. In conclusion, adopting an external focus of attention led to better overall movement performance when performing a lower extremity Fitts' task. The task used in the present study can distinguish between APAs for older and young adults. We recommend that future studies expand on our findings in order to establish a performance-based objective measure of APAs to assess clinical interventions for postural control impairment.

The immediate influence of implicit motor learning strategies on spatiotemporal gait parameters in stroke patients: a randomized within-subjects design

OBJECTIVES:

To investigate immediate changes in walking performance associated with three implicit motor learning strategies and to explore patient experiences of each strategy.

DESIGN:

Participants were randomly allocated to one of three implicit motor learning strategies. Within-group comparisons of spatiotemporal parameters at baseline and post strategy were performed.

SETTING:

Laboratory setting.

SUBJECTS:

A total of 56 community-dwelling post-stroke individuals.

INTERVENTIONS:

Implicit learning strategies were analogy instructions, environmental constraints and action observation. Different analogy instructions and environmental constraints were used to facilitate specific gait parameters. Within action observation, only videotaped gait was shown.

MAIN MEASURES:

Spatiotemporal measures (speed, step length, step width, step height) were recorded using Vicon 3D motion analysis. Patient experiences were assessed by questionnaire.

RESULTS:

At a group level, three of the four analogy instructions ( n = 19) led to small but significant changes in speed ( d = 0.088 m/s), step height (affected side d = 0.006 m) and step width ( d = -0.019 m), and one environmental constraint ( n = 17) led to significant changes in step width ( d = -0.040 m). At an individual level, results showed wide variation in the magnitude of changes. Within action observation ( n = 20), no significant changes were found. Overall, participants found it easy to use the different strategies and experienced some changes in their walking performance.

CONCLUSION:

Analogy instructions and environmental constraints can lead to specific, immediate changes in the walking performance and were in general experienced as feasible by the participants. However, the response of an individual patient may vary quite considerably.